Is anterior knee pain following anterior cruciate ligament reconstruction a consideration for graft choice, and the influence of COVID: a qualitative analysis in recreational athletes.

BACKGROUND: We set out to investigate whether anterior knee pain following anterior cruciate ligament reconstruction has a significant effect on patients, and whether it should influence graft choice. METHODS: This was a qualitative analysis of a set of recreational athletes treated at a university hospital at about 1 year following anterior cruciate ligament reconstruction surgery. Participants were interviewed by an orthopaedic fellow and resident using structured, open-ended questions. Inductive theme analysis was used to code the data. RESULTS: There were 4 major themes: (1) Our hypothesis was that patients would be given adequate information to make an appropriate graft choice. This hypothesis was rejected. Discussion took place, but with little details or rationale for the graft choice. The predominant theme was that the surgeon made the decision, and there was a lack of reliable information for the patient to make a choice. (2) The overall theme was that most patients had no anterior knee pain, and it did not interfere with activities of daily living. (3) One theme was that patients were able to resume all sports without restriction, but in some, the anterior knee pain interfered with the more demanding activities such as impact, cutting, and pivoting. A separate theme was that fear was a major impediment to return to sports and was not related to the anterior knee pain. (4) The overriding theme was that the generalized closures associated with the COVID-19 pandemic slowed the rehabilitation process. Although virtual care was available in general, it was not particularly satisfactory. Patients indicated that they had not been able to return to the gym or to their sporting activities as a result. CONCLUSIONS: Amongst non-competitive athletes, anterior knee pain post-anterior cruciate ligament reconstruction surgery does not significantly affect activities of daily living. Although there is a minor effect on sporting activities, the inability to return to sports is related to factors such as the COVID-19 pandemic, fear, or insufficient rehabilitation, rather than anterior knee pain. Overall, anterior knee pain is not a significant factor that plays a role in determining graft choice.

Wie wichtig sind psychologische Maßnahmen, um die Bereitschaft zur Rückkehr zum Sport nach der Rekonstruktion des vorderen Kreuzbandes zu bestimmen? Ergebnisse einer Online-Umfrage.

BACKGROUND: Recent studies have suggested that psychological factors are important components of a successful return to sports (RTS) after anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to survey physicians with respect to their criteria used to determine readiness to RTS after ACLR and to understand the significance of psychological factors on RTS. METHODS: A survey was designed to understand the practices of clinicians managing rehabilitation after ACLR, consisting of 25 questions divided into 3 different sections, including one section about psychological scores and factors affecting RTS. The survey was delivered to three North American organizations for orthopedic sports medicine. RESULTS: The total number of respondents was 113. Of the respondents, 95% considered psychological tests at least "somewhat important" (33% "important", 23% selected "very important"). Routine use of psychological tests in practice was only reported by 35% of respondents. The ACL-Return to Sport after Injury Scale was the most frequently used psychological test (23%). Fear of reinjury was considered the most common patient-cited psychological factor affecting RTS. Psychological factors ranked 8th out of 9 outcomes measures in determining readiness to RTS. CONCLUSION: This study demonstrates a discrepancy between the importance of psychological tests and the frequency of use in practice. Additional education on this topic, web-based applications, and a multidisciplinary approach may increase the usage of psychological tests to determine RTS after ACLR.

Wide Variability in Return-to-Sport Criteria used by Team Physicians After Anterior Cruciate Ligament Reconstruction in Elite Athletes-A Qualitative Study.

Purpose: The purpose of this study is to explore currently used readiness to return to sport (RTS) criteria after anterior cruciate ligament reconstruction (ACLR) used in elite athletes to gain novel insights into the RTS decision-making process of professional team physicians. Methods: Eighteen qualitative semistructured interviews with professional team physicians were conducted by a single trained interviewer. The interviews were used to identify team physician concepts and themes regarding the criteria used to determine RTS after ACLR. General inductive analysis and a coding process were used to identify themes and subthemes arising from the data. A hierarchical approach in coding helped to link themes. Results: The most important RTS criteria included muscle strength, followed by satisfactory functional testing including hop tests, a satisfactory clinical examination, joint stability, psychological readiness, time since the ACLR surgery, absence of joint effusion, subjective feeling of knee stability, pain-free return to sporting movements, completion of a sport-specific rehabilitation, and at last allied team support. Conclusions: This study identified 4 main themes, including (1) objective findings, (2) informative feedback of the team members, (3) subjective findings, and (4) type of sport and time to surgery as having the most influence on RTS decision after ACLR. However, interviews showed that even among professional team physicians, the main criteria to RTS in these categories were inconsistent. A definitive set of conclusive guidelines could not be established and would be a fruitful and useful area for future research through further quantitative studies and international consensus meetings along the foundation of the presenting study. Level of Evidence: V, evidence-based practices, qualitative study.

Characterization of Migratory Cells From Bioengineered Bovine Cartilage in a 3D Co-culture Model.

BACKGROUND: Chondrocyte migration in native cartilage is limited and has been implicated as one of the reasons for the poor integration of native implants. Through use of an in vitro integration model, it has previously been shown that cells from bioengineered cartilage can migrate into the native host cartilage during integration. Platelet-rich plasma (PRP) treatment further enhanced integration of bioengineered cartilage to native cartilage in vitro. However, it is not known how PRP treatment of the bioengineered construct promotes this. HYPOTHESIS: PRP supports cell migration from bioengineered cartilage and these migratory cells have the ability to accumulate cartilage-like matrix. STUDY DESIGN: Controlled laboratory study. METHODS: Osteochondral-like constructs were generated by culturing primary bovine chondrocytes on the top surface of a porous bone substitute biomaterial composed of calcium polyphosphate. After 1 week in culture, the constructs were submerged in PRP and placed adjacent, but 2 mm distant, to a native bovine osteochondral plug in a co-culture model for 2 weeks. Cell migration was monitored using phase-contrast imaging. Cell phenotype was determined by evaluating the gene expression of matrix metalloprotease 13 (MMP-13), Ki67, and cartilage matrix molecules using quantitative polymerase chain reaction. When tissue formed, it was assessed by histology, immunohistochemistry, and quantification of matrix content. RESULTS: PRP treatment resulted in the formation of a fiber network connecting the bioengineered cartilage and native osteochondral plug. Cells from both the bioengineered cartilage and the native osteochondral tissue migrated onto the PRP fibers and formed a tissue bridge after 2 weeks of culture. Migratory cells on the tissue bridge expressed higher levels of collagen types II and I (COL2, COL1), Ki67 and MMP-13 mRNA compared with nonmigratory cells in the bioengineered cartilage. Ki67 and MMP-13-positive cells were found on the edges of the tissue bridge. The tissue bridge accumulated COL1 and COL2 and aggrecan and contained comparable collagen and glycosaminoglycan content to the bioengineered cartilage matrix. The tissue bridge did not reliably develop in the absence of cells from the native osteochondral plug. CONCLUSION: Bioengineered cartilage formed by bovine chondrocytes contains cells that can migrate on PRP fibers and form cartilaginous tissue. CLINICAL RELEVANCE: Migratory cells from bioengineered cartilage may promote cartilage integration. Further studies are required to determine the role of migratory cells in integration in vivo.

Six Percent Incidence of Graft-Tunnel Mismatch in Anatomic Anterior Cruciate Ligament Reconstruction Using Bone-Patella Tendon-Bone Autograft and Anteromedial Portal Drilling.

Purpose: The purpose of this study was to determine the incidence of graft-tunnel mismatch (GTM) when performing anatomic anterior cruciate ligament reconstruction (ACLR) using bone-patella tendon-bone (BPTB) grafts and anteromedial portal drilling. Methods: Beginning in November 2018, 100 consecutive patients who underwent ACLR by two sports fellowship-trained, orthopedic surgeons using BPTB autograft and anteromedial portal drilling were prospectively identified. The BPTB graft dimensions and the femoral tunnel distance, tibial tunnel distance, intra-articular distance, and total distance were measured. Surgeons determined the depth and angle of tunnels based on the patella tendon graft length dimensions in each case. After passage of the graft, the distance from the distal graft tip to the tibial cortex aperture was measured. GTM was defined as the need for additional measures to obtain satisfactory tibial graft fixation (<15-20 mm of bone fixation). Results: The incidence of mismatch was 6/100 (6%). Five cases involved the graft being too long, with the tibial bone plug protruding excessively from the tibial tunnel-4/5 had a patella tendon length ≥ 50 mm. Three cases were managed with femoral tunnel recession, and two were treated with a free bone plug technique. One patient with a patella tendon length of 35 mm had a graft that was too short, with the tibial bone plug recessed in the tibial tunnel. Of patients whose tibial tunnel distance was within 5 mm of the patella tendon length, only 1/46 (2%) patients had mismatch, whereas 5/54 (9%) of patients who had >5 mm difference had mismatch. Conclusions: The incidence of graft-tunnel mismatch after anatomic ACLR using BTPB and anteromedial portal drilling in this study is 6%. To limit the occurrence of GTM where the graft is too long, surgeons should drill tibial tunnel distances within 5 mm of the patella tendon length. Clinical Relevance: The results of this study provide surgeons with a technique of limiting graft tunnel mismatch when performing ACLR using BPTB and anteromedial portal drilling.

Venous Thromboembolism in Patients Discharged From the Emergency Department With Ankle Fractures: A Population-Based Cohort Study.

STUDY OBJECTIVE: Temporary lower limb immobilization may be a risk for venous thromboembolism. The purpose of this study was to examine the 90-day incidence of venous thromboembolism among patients discharged from an emergency department (ED) with ankle fractures requiring temporary immobilization. Secondary objectives were to examine individual factors associated with venous thromboembolism in this population and to compare the risk of venous thromboembolism in patients with ankle fractures against a priori-selected control groups. METHODS: This was a retrospective cohort study using province-wide health datasets from Ontario, Canada. We included patients aged 16 years and older discharged from an ED between 2013 and 2018 with closed ankle fractures requiring temporary immobilization. We estimated 90-day incidence of venous thromboembolism after ankle fracture. A Cox proportional hazards model was used to evaluate risk factors associated with venous thromboembolism, censoring at 90 days or death. Patients with ankle fractures were then propensity score matched to 2 control groups: patients discharged with injuries not requiring lower limb immobilization (ie, finger wounds and wrist fractures) to compare relative hazard of venous thromboembolism. RESULTS: There were 86,081 eligible patients with ankle fractures. Incidence of venous thromboembolism within 90 days was 1.3%. Factors associated with venous thromboembolism were older age (hazard ratio [HR]: 1.18; 95% confidence interval [CI]: 1.00 to 1.39), venous thromboembolism or superficial venous thrombosis history (HR: 5.18; 95% CI: 4.33 to 6.20), recent hospital admission (HR: 1.33; 95% CI: 1.05 to 1.68), recent nonankle fracture surgery (HR: 1.58; 95% CI: 1.30 to 1.93), and subsequent surgery for ankle fracture (HR: 1.80; 95% CI: 1.48 to 2.20). In the matched cohort, patients with ankle fractures had an increased hazard of venous thromboembolism compared to matched controls with finger wounds (HR: 6.31; 95% CI: 5.30 to 7.52) and wrist fractures (HR: 5.68; 95% CI: 4.71 to 6.85). CONCLUSION: The 90-day incidence of venous thromboembolism among patients discharged from the ED with ankle fractures requiring immobilization was 1.3%. These patients had a 5.7- to 6.3-fold increased hazard compared to matched controls. Certain patients immobilized for ankle fractures are at higher risk of venous thromboembolism, and this should be recognized by emergency physicians.

The Effects of Blood Flow Restriction in Patients Undergoing Knee Surgery: A Systematic Review and Meta-analysis.

BACKGROUND: Blood flow restriction (BFR) training has been shown to have beneficial effects in reducing quadriceps muscle atrophy and improving strength in patients with various knee pathologies. Furthermore, the effectiveness of BFR training in patients undergoing knee surgery has been investigated to determine if its use can improve clinical outcomes. PURPOSE/HYPOTHESIS: The purpose of this study was to conduct a systematic review and meta-analysis to examine the effectiveness of BFR training in patients undergoing knee surgery. We hypothesized that BFR, before or after surgery, would improve clinical outcomes as well as muscle strength and volume. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: This systematic review and meta-analysis of peer-reviewed literature was conducted using PubMed, Embase, and Cochrane databases from 1980 to present. Search results were limited to those assessing BFR training in patients undergoing knee surgery published in a scientific peer-reviewed journal in English. Selected studies subsequently underwent data extraction, methodological quality assessment, and data analysis. RESULTS: Eleven studies were eligible, including anterior cruciate ligament reconstruction (n = 10) and knee arthroscopy (n = 1). Two studies specifically assessed BFR use in the preoperative time frame. For the meta-analysis, including 4 studies, the primary outcome variables included the cross-sectional area of the quadratus femoris muscle group assessed with magnetic resonance imaging or ultrasonography, and patient-reported outcome measure scores. The results demonstrated that BFR use in the postoperative time period can lead to a significant improvement in the cross-sectional area when quantifying muscle atrophy. However, there were no significant differences found for patient-reported outcome measures between the included studies. It should be noted that 4 of the included papers in this review reported increases in clinical strength when using BFR in the postoperative setting. Last, preoperative BFR training did not show any significant clinical benefit between the 2 studies. CONCLUSION: This is the first systematic review and meta-analysis to study the effects of BFR in patients undergoing knee surgery. The results of this analysis show that BFR in the postoperative period after knee surgery can improve quadriceps muscle bulk compared with a control group. However, future research should examine the effects of preconditioning with BFR before surgery. Lastly, BFR protocols need to be further investigated to determine which provide the best patient outcomes. This will help standardize this type of treatment modality for future studies.

Anterior Cruciate Ligament Patellar Tendon Autograft Fixation at 0° Versus 30° Results in Improved Activity Scores and a Greater Proportion of Patients Achieving the Minimal Clinical Important Difference For Knee Injury and Osteoarthritis Outcome Score Pain: A Randomized Controlled Trial.

PURPOSE: The aim of the current study was to determine the effect of the knee flexion angle (KFA) during tibial anterior cruciate ligament (ACL) graft fixation on patient-reported outcomes, graft stability, extension loss, and reoperation after anatomic single-bundle ACL reconstruction. METHODS: All 169 included patients (mean age 28.5 years, 65% male) were treated with anatomic single-bundle ACL reconstruction using patellar tendon autograft and were randomized to tibial fixation of the ACL graft at either 0° (n = 85) or 30° (n = 84). The primary outcome was the Knee Injury and Osteoarthritis Outcome Score (KOOS) 2 years after surgery. Secondary outcomes were the Marx Activity Scale (MAS), the rate of reoperation, and physical examination findings at 1 year, including KT-1000 and side-to-side differences in knee extension. RESULTS: The follow-up rate was 82% (n = 139) for the primary outcome. Graft failure rate at 2 years was 1% (n = 2, 1 per group). ACL tibial graft fixation at 0° or 30° did not have a significant effect on KOOS scores at 2 years after ACLR. Patients whose graft was fixed at a knee flexion angle of 0° had greater scores on the MAS (mean 9.6 95% confidence interval [CI] 8.5 to 10.6, versus 8.0, 95% CI 6.9 to 9.1; P = .04), and a greater proportion achieved the minimal clinical important difference (MCID) for the KOOS pain subdomain (94% versus 81%; P = .04). There was no significant difference in knee extension loss, KT-1000 measurements, or reoperation between the 2 groups. CONCLUSION: In the setting of anatomic single-bundle ACLR using patellar tendon autograft and anteromedial portal femoral drilling, there was no difference in KOOS scores between patients fixed at 0° and 30°. Patient fixed in full extension did demonstrate higher activity scores at 2 years after surgery and a greater likelihood of achieving the MCID for KOOS pain. LEVEL OF EVIDENCE: II, prospective randomized trial.

Systematic Arthroscopic Treatment of Synovial Chondromatosis of the Knee.

Synovial chondromatosis is a benign metaplastic disease of the synovial joints, characterized by the development of cartilaginous nodules in the synovium. Treatment generally includes open or arthroscopic loose body removal combined with a synovectomy. An all-arthroscopic approach has been described to minimize complications and reduce morbidity while providing adequate control of local disease. The purpose of this Technical Note is to describe our techniques and technical pearls that allow for adequate excision of disease while minimizing complications and disease recurrence. The combination of patient positioning, the establishment of multiple arthroscopic portals to ensure optimal visualization and freedom of instruments, the use of a leg holder, and the use of a variety of surgical instruments to facilitate loose body removal and synovectomy is critical to optimize clinical outcomes and minimize complications. Although technically demanding, our described technique can help facilitate extensive loose body removal and complete synovectomy.

Injection of Bone Marrow Aspirate for Glenohumeral Joint Osteoarthritis: A Pilot Randomized Control Trial.

PURPOSE: To compare the efficacy of a single, intra-articular, nonconcentrated bone marrow aspirate (BMA) injection in comparison to cortisone for the treatment of glenohumeral joint osteoarthritis (GHJ OA). METHODS: Inclusion criteria were patients between the ages of 18 and 75 with a diagnosis of GHJ OA on radiograph. Patients were randomized to receive an ultrasound-guided, intra-articular cortisone injection or BMA injection (without concentration). The primary outcome measure was the Western Ontario Osteoarthritis of the Shoulder (WOOS) index at 12 months. Secondary outcome measures were the QuickDASH, EuroQOL 5-dimensions 5-level questionnaire (EQ-5D-5L) and visual analogue scale. RESULTS: The study included 25 shoulders of 22 patients who completed baseline and 12 months' patient-reported outcome measures (12 shoulders received cortisone, 13 shoulders received BMA) after the study was terminated early by changes in Health Canada regulations. Baseline characteristics demonstrated a significant difference in the ages of the 2 groups, with the BMA group being older (61.6 vs 53.8 mean years, P = 0.021). For the BMA group, a significant improvement was seen in the WOOS index (P = 0.002), the QuickDASH (P < 0.001), and the EQ-5D-5L pain dimension (P = 0.004) between baseline and 12 months. No significant difference was seen for any outcome in the cortisone group between baseline and 12 months. No significant difference was demonstrated between changes in the WOOS scores from baseline to 12 months when compared between groups (P = 0.07). However, a significant difference in changes in scores was seen in the QuickDASH (P = 0.006) and the EQ-5D-5L pain scores (P = 0.003) and the EQ-5D-5L health scores (P = 0.032) in favor of BMA. CONCLUSIONS: The results of this study demonstrate that patients with GHJ OA treated with BMA have superior changes in the QuickDASH and EQ-5D-5L pain and health scores but not in the WOOS outcomes measures at 12 months post injection when compared to patients treated with cortisone. However, because of the limited number of patients as a result of the early termination of the study, larger randomized studies are required to confirm these findings. LEVEL OF EVIDENCE: Level II, randomized controlled trial.

Preoperative Magnetic Resonance Imaging Accurately Detects the Arthroscopic Comma Sign in Subscapularis Tears.

PURPOSE: To assess the accuracy and reliability of routine preoperative magnetic resonance imaging (MRI) in the detection of the comma sign compared with the gold standard of arthroscopic findings. METHODS AND MATERIALS: Preoperative MRI exams in consecutive patients undergoing arthroscopic subscapularis tendon repair, over a 5-year time frame, were retrospectively reviewed for full-thickness tears of the subscapularis and supraspinatus tendons, fatty atrophy of the subscapularis and supraspinatus muscles, and status of the long head of the biceps tendon. Each case was also evaluated for presence or absence of a comma sign on MRI. Surgical findings served as the diagnostic standard of reference in determination of a comma sign. RESULTS: The study cohort included 45 male and 10 female patients (mean age, 56; range, 32-80 years). A comma sign was present at arthroscopy in 19 patients (34.5%). Interclass and intrarater correlation showed 100% agreement in preoperative assessment of a comma sign on MRI. MRI showed an overall accuracy of 83.6% in diagnosis of a comma sign (sensitivity, 63.2%; specificity, 94.4%; positive predictive value, 85.7%; negative predictive value, 82.9%; positive likelihood ratio, 11.37; negative likelihood ratio, 0.39). No statistically significant association was observed between an arthroscopic comma sign and patient demographics or MRI findings of full-thickness rotator cuff tears, muscle fatty atrophy, or long head of the biceps tendon pathology. CONCLUSIONS: MR imaging illustrates excellent reliability and good specificity and accuracy in detection of the arthroscopic comma sign in the setting of subscapularis tendon tearing. Detection of a comma sign on MRI may be important preoperative planning information in the arthroscopic management of patients with subscapularis tendon tears. LEVEL OF EVIDENCE: Level IV, retrospective diagnostic study.

A Comparison of Quadriceps Tendon Autograft With Bone-Patellar Tendon-Bone Autograft and Hamstring Tendon Autograft for Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review and Quantitative Synthesis.

OBJECTIVE: There is growing enthusiasm for the increased use of quadriceps tendon (QT) autograft for primary anterior cruciate ligament reconstruction (ACLR). The purpose of this analysis was to synthesize and quantitatively assess the available evidence comparing QT autograft with hamstring tendon (HT) and bone-patellar tendon-bone (BPTB) autografts, regarding functional outcomes, knee stability, anterior knee pain, and revision rates. DATA SOURCES: A search in MEDLINE, EMBASE, PubMed, and the Cochrane Central Register of Controlled Trials for eligible studies up to May 2018 was conducted. Two reviewers selected studies based on inclusion criteria and assessed methodological quality. Outcomes analyzed were anterior knee pain, graft failure rates, knee stability, functional outcomes, and adverse events. Pooled analyses were performed for continuous and dichotomous variables where appropriate. MAIN RESULTS: Ten studies (1 randomized trial and 9 nonrandomized cohorts) met our inclusion criteria, which included 1398 patients. The analysis showed no statistical difference in anterior knee pain when comparing QT and HT autografts, but a significant difference between QT and BPTB autografts [odds ratio, 0.15 (95% confidence interval, 0.08-0.27); P < 0.001]. There were no differences between all 3 autografts in revision rates, knee stability, and patient-reported functional outcomes. CONCLUSIONS: Quadriceps tendon autograft is a suitable graft alternative for primary ACLR, as it achieves good clinical outcomes with a low incidence of anterior knee pain. Given the limited quality of the included studies, there is a need for a well-designed multicenter randomized control trial comparing QT autograft with other primary ACL autografts to confirm our findings. LEVEL OF EVIDENCE: Level IV systematic review.

Postoperative Pain Is Associated With Psychological and Physical Readiness to Return to Sports One-Year After Anterior Cruciate Ligament Reconstruction.

PURPOSE: To identify whether any patient factors, injury factors, or symptom severity scores are associated with either psychological or physical readiness to return to sport after anterior cruciate ligament reconstruction (ACLR). METHODS: Consecutive patients with an ACL injury that required surgical treatment were included in this study. All patients completed the single-legged hop testing and the Anterior Cruciate Ligament Return to Sport Index (ACL-RSI) at 1 year postoperatively. Multivariable regression analysis models were used to determine whether an independent relationship existed between baseline patient factors (age, sex, BMI, preinjury Marx Activity Score), injury factors (meniscal tear and chondral injury), physical symptoms (Knee Injury and Osteoarthritis Outcome Score [KOOS] for pain and symptoms), and the dependent variables of physical and psychological readiness to return to sport (single-legged hop and ACL-RSI). RESULTS: Of the 113 patients who were included, 37% were female, and the mean age of our population was 28.2 years (SD = 8.1). Multivariable regression models demonstrated that patient-reported pain symptoms at 1 year postoperatively, as measured by the KOOS pain subscale, was significantly associated with both ACL-RSI score (Beta estimate: 1.11 [95% CI: .62-1.60] P < .001) and the ability to pass the single-legged hop test (OR: 1.07 [95% CI: 1.004-1.142] P = .037). CONCLUSIONS: Patients with higher reported pain levels at 1 year following ACLR have lower psychological and physical readiness to return to sport. LEVEL OF EVIDENCE: Level 3, retrospective cohort study.

Acromioclavicular Joint Injuries in Professional Ice Hockey Players: Epidemiologic and MRI Findings and Association With Return to Play.

BACKGROUND: Acromioclavicular joint (ACJ) injuries are common in ice hockey players and are traditionally evaluated with conventional radiography, which has recognized limitations in the accurate characterization of the spectrum of soft tissue injuries and severity/grade of injury sustained. PURPOSE: To evaluate the epidemiologic, clinical, and magnetic resonance imaging (MRI) findings in professional ice hockey players who have sustained acute ACJ injuries. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review was performed of professional National Hockey League (NHL) players referred for MRI evaluation of acute ACJ injuries. All MRI scans were assessed for status of the ACJ, ligamentous stabilizers, and surrounding musculature. MRI-based overall grade of ACJ injury (modified Rockwood grade 1-6) was assigned to each case. Data regarding mechanism of injury, player handedness, clinical features, and return to play were evaluated. RESULTS: Overall, 24 MRI examinations of acute ACJ injuries (23 patients; mean age, 24 years) were reviewed. We found that 50% of injuries were sustained during the first period of play, and in 75% of cases, injuries involved the same side as player shooting handedness. Analysis of MRI scans revealed 29% (7/24) grade 1 ACJ injuries, 46% (11/24) grade 2 injuries, 21% (5/24) grade 3 injuries, and 4% (1/24) grade 5 injuries. Trapezius muscle strains were seen in 79% and deltoid muscle strain in 50% of cases. Nonoperative management was used for 23 injuries; 1 patient (grade 5 injury) underwent acute reconstructive surgery. All players successfully returned to professional NHL competition. Excluding cases with additional injuries or surgery (n = 3) or convalescence extending into the offseason (n = 3), we found that the mean return to play was 21.4 days (7.2 games missed). No statistically significant difference was observed in return to play between nonoperatively treated grade 3 injuries (mean, 28.3 days) and grade 1 or 2 injuries (mean, 20.1 days). However, grade 3 injuries were associated with a greater number of NHL scheduled games missed (mean, 12.7) compared with lower grade injuries (mean, 6.1) (P = .027). CONCLUSION: The spectrum of pathology and grading of acute ACJ injuries sustained in professional ice hockey can be accurately assessed with MRI; the majority of injuries observed in this study were low grade (grades 1 and 2). Although grade 3 injuries were associated with a greater number of games missed, similar return-to-play results were observed between nonoperatively treated grade 3 and grade 1 or 2 ACJ injuries.

Clinical applications of ultrasonography in the shoulder for the Orthopedic Surgeon: A systematic review.

BACKGROUND: Ultrasound imaging offers a non-invasive method to visualize the anatomy and function of the musculoskeletal system. Despite its benefits and widespread adoption in medicine, ultrasonography is still not well utilized by orthopaedic surgeons. The purpose of this systematic review was to provide a better understanding of the diagnostic accuracy and clinical utility of ultrasound of the shoulder for orthopaedic surgeons. METHODS: We searched Medline, Embase, Web of Science, and Scopus databases. Our search terms included orthopedic, orthopedic surgery, ultrasonography, and shoulder. Inclusion criteria consisted of studies that used bedside ultrasound for the diagnosis and therapy of patients with common clinical entities of the shoulder presenting to orthopedic clinics, to demonstrate the utility for orthopedic surgeons. We reported sensitivity, specificity, positive predictive value, negative predictive value. Studies were excluded if they used non-diagnostic ultrasound modalities (e.g. shock wave therapy, shear wave elastography, Doppler flowmetry, speckle tracking shear strain, vibro-acoustography). RESULTS: Our search strategy yielded 771 of potentially relevant publications, 41 studies were retrieved for full text screening, and 24 were included in this systematic review. We found that ultrasound used in orthopedic clinics has good sensitivity and high specificity for the assessment of partial and full rotator cuff tears of the shoulder, including post-operative cuff repairs. There was some evidence that it may also be useful for the diagnosis of subacromial-subdeltoid bursitis, AC joint arthropathy, and labral tears; however further investigations are still required. Ultrasound improves that accuracy of injections into spaces of the shoulder (subacromial bursa, acromioclavicular joint, glenohumeral joints, and the long head of biceps tendon sheath) compared to landmark guided injections, that can be helpful for diagnostic purposes, but do not improve long term clinical outcomes. DISCUSSION: We reviewed the literature for orthopaedic surgeons and show that ultrasound of the shoulder can be a useful diagnostic tool for orthopedic surgeons in outpatient clinics. We found no difference in sensitivity or specificity when ultrasound was performed at bedside by orthopedic surgeons or by radiologists for patients referred to orthopedic clinic.

The use of GPS and inertial devices for player monitoring in team sports: A review of current and future applications.

Player-worn devices, combining global positioning system and inertial monitors, are being used increasingly by professional sports teams. Recent interest focusses on using the data generated to track trainingload and whether this may lead to more effective training prescription with better management of injury risk. The aim of this review is to summarize the development and current use of this technology alongside proposed future applications. PubMed and Medline searches (2000-2017) identified all relevant studies involving use in team sports or comparative studies with other accepted methods. Our review determined that the latest devices are valid and reliably track activity levels. This technology is both accurate and more efficient than previous methods. Furthermore, recent research has shown that measurable changes in trainingload (the acute-to-chronic load ratio) are related to injury risk. However, results remain very sport specific and generalization must be done with caution. Future uses may include injury-prevention strategies and return-to-play judgement.

Conventional Follow-up Versus Mobile Application Home Monitoring for Postoperative Anterior Cruciate Ligament Reconstruction Patients: A Randomized Controlled Trial.

PURPOSE: To determine whether a mobile app can reduce the need for in-person visits and examine the resulting societal cost differences between mobile and conventional follow-up for postoperative anterior cruciate ligament (ACL) reconstruction patients. METHODS: Study design was a single-center, 2-arm parallel group randomized controlled trial. All patients undergoing ACL reconstruction aged 16 to 70 years were screened for inclusion in the study. Competent use of a mobile device and ability to communicate in English was required. Patients were randomly assigned to receive follow-up via a mobile app or conventional appointments. Analysis was intention-to-treat. The primary outcome was the number of in-person visits to any health care professional during the first 6 postoperative weeks. Secondary outcomes included analysis of costs incurred by the health care system and personal patient costs related to both methods of follow-up. Patient-reported satisfaction and convenience scores, rates of complications, and clinical outcomes were also analyzed. RESULTS: Sixty patients were analyzed. Participants in the app group attended a mean of 0.36 in-person visits versus 2.44 in-person visits in the conventional group (95% confidence interval 0.08-0.28; P < .0001). On average, patients in the app group spent $211 (Canadian dollars) less than the conventional group over 6 weeks (P < .0001) on personal costs related to follow-up. Health care system costs were also significantly less in the app group ($157.5 vs CAD $202.2; P < .0001). There was no difference between groups in patient satisfaction, convenience, complication rates, or clinical outcome measures. CONCLUSIONS: Mobile follow-up can eliminate a significant number of in-person visits during the first 6 postoperative weeks in patients undergoing ACL reconstruction with cost savings to both the patient and health care system. This method should be considered for dissemination among similar orthopaedic procedures during early postoperative care. LEVEL OF EVIDENCE: I: Prospective randomized controlled trial.

Development of a certification examination for orthopedic sports medicine fellows

Background: The purpose of this study was to develop a multifaceted examination to assess the competence of fellows following completion of a sports medicine fellowship. Methods: Orthopedic sports medicine fellows over 2 academic years were invited to participate in the study. Clinical skills were evaluated with objective structured clinical examinations, multiple-choice question examinations, an in-training evaluation report and a surgical logbook. Fellows' performance of 3 technical procedures was assessed both intraoperatively and on cadavers: anterior cruciate ligament reconstruction (ACLR), arthroscopic rotator cuff repair (RCR) and arthroscopic shoulder Bankart repair. Technical procedural skills were assessed using previously validated task-specific checklists and the Arthroscopic Surgical Skill Evaluation Tool (ASSET) global rating scale. Results: Over 2 years, 12 fellows were assessed. The Cronbach α for the technical assessments was greater than 0.8, and the interrater reliability for the cadaveric assessments was greater than 0.78, indicating satisfactory reliability. When assessed in the operating room, all fellows were determined to have achieved a minimal level of competence in the 3 surgical procedures, with the exception of 1 fellow who was not able achieve competence in ACLR. When their performance on cadaveric specimens was assessed, 2 of 12 (17%) fellows were not able to demonstrate a minimal level of competence in ACLR, 2 of 10 (20%) were not able to demonstrate a minimal level of competence for RCR and 3 of 10 (30%) were not able to demonstrate a minimal level of competence for Bankart repair. Conclusion: There was a disparity between fellows' performance in the operating room and their performance in the high-fidelity cadaveric setting, suggesting that technical performance in the operating room may not be the most appropriate measure for assessment of fellows' competence.

Contexte: Le but de cette étude était de concevoir un examen à plusieurs volets pour évaluer la compétence des moniteurs cliniques à la fin de leur formation en médecine sportive. Méthodes: Après leur formation de 2 ans pour devenir orthopédistes en médecine sportive, les moniteurs cliniques ont été invités à participer à l'étude. Leurs habiletés cliniques ont été évaluées au moyen d'examens cliniques objectifs structurés, de questionnaires à choix multiple, d'un rapport d'évaluation en cours de formation et d'un journal de bord chirurgical. Leur habileté à réaliser 3 techniques chirurgicales différentes a été évaluée au bloc opératoire et sur des cadavres : reconstruction du ligament croisé antérieur (RLCA), réparation arthroscopique de la coiffe des rotateurs (RACR) et intervention de Bankart sous endoscopie pour l'épaule. Les habiletés techniques ont été évaluées au moyen de listes de vérification spécifiques aux tâches validées et au moyen de l'outil d'évaluation globale ASSET (Arthroscopic Surgical Skill Evaluation). Résultats: Sur une période de 2 ans, 12 moniteurs ont été évalués. Le coefficient α de Cronbach pour les évaluations techniques a été supérieur à 0,8, et la fiabilité inter-examinateurs pour l'évaluation des interventions sur des cadavres a été supérieure à 0,78, soit une fiabilité jugée satisfaisante. Lors de l'évaluation au bloc opératoire, on a jugé que tous les moniteurs détenaient le niveau minimum de compétences pour exécuter les 3 techniques chirurgicales, à l'exception d'un seul qui n'a pas atteint le niveau de compétence pour la RLCA. À l'évaluation de leurs compétences pour les interventions sur des cadavres, 2 sur 12 (17 %) n'ont pas atteint le niveau minimum de compétence pour la RLCA, 2 sur 10 (20 %) pour la RACR et 3 sur 10 (30 %) pour l'intervention de Bankart. Conclusion: On a noté une disparité dans la compétence des moniteurs entre le bloc opératoire et le contexte cadavérique haute fidélité, ce qui donne à penser que le rendement technique au bloc opératoire pourrait ne pas être le moyen le plus approprié d'évaluer la compétence des moniteurs cliniques.

Determining the Patient Acceptable Symptomatic State for Patients Undergoing Arthroscopic Partial Meniscectomy in the Knee.

BACKGROUND: Arthroscopic partial meniscectomy is one of the most common procedures in orthopaedic surgery. The patient acceptable symptomatic state (PASS), which defines a level of symptoms above which patients consider themselves well, remains to be well-defined in this population. PURPOSE: Using an anchor-based approach, our goal was to determine the 1-year PASS for the Knee injury and Osteoarthritis Outcome Score (KOOS), the International Knee Documentation Committee (IKDC) Subjective Knee Form, the Western Ontario Meniscal Evaluation Tool (WOMET), and the Marx Activity Scale (MAS) in patients who were treated with partial knee meniscectomy. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A consecutive series of patients with knee meniscal tears and a Kellgren-Lawrence grade of 0 to 2 treated with arthroscopic partial meniscectomy were eligible. The KOOS (0-100), IKDC (0-100), WOMET (0-100), and MAS (0-16) were administered at baseline and 12 months postoperatively. An external anchor question at 1 year postoperatively was used to determine PASS values. A receiver operating characteristic curve (ROC) analysis was used to determine the PASS value at which patients considered their status to be satisfactory. RESULTS: The study included 110 patients (mean ± SD age, 53.8 ± 12.0 years), 57.3% were male, and the follow-up rate was 82%. In total, 70% of patients had an Outerbridge arthroscopic grade of 2 or lower. Based on ROC analysis, the 1-year postoperative PASS values (sensitivity, specificity) were 64.3 (47.8, 100.0) for KOOS Symptoms, 81.6 (71.6, 100.0) for KOOS Pain, 82.4 (82.1, 86.4) for KOOS Function in Daily Living, 71.0 (62.7, 81.8) for KOOS Function in Sport and Recreation, 51.0 (83.6, 95.5) for KOOS Knee-Related Quality of Life, 56.2 (82.1, 100.0) for IKDC, 58.5 (79.1, 100.0) for WOMET, and 7.0 (44.8, 68.2) for MAS. Baseline scores did not affect the PASS threshold across the different instruments. However, patients with higher baseline scores were more likely to achieve the PASS for the KOOS Symptoms (odds ratio [OR], 2.808; P = .047), IKDC (OR, 4.735; P = .006), and WOMET (OR, 2.985; P = .036). Age, sex, and cartilage status were not significantly related to the odds of achieving the PASS for any of the patient-reported outcome measures. CONCLUSION: These findings allow researchers and clinicians to determine whether partial meniscectomy is meaningful to patients at the individual level and will be helpful for responder analysis in future trials related to the treatment of meniscal abnormality.

High Ankle Sprains in Professional Ice Hockey Players: Prognosis and Correlation Between Magnetic Resonance Imaging Patterns of Injury and Return to Play.

BACKGROUND: Hockey players sustain a greater incidence of ankle syndesmosis injuries than other athletes. These injuries have a higher morbidity and more unpredictable recovery than lateral ankle sprains. Magnetic resonance imaging (MRI) has been used to establish the diagnosis but has not been evaluated for its ability to predict return to play. HYPOTHESIS: We hypothesized that patterns of injury defined on MRI could be used to predict return to play in a cohort of professional hockey players with syndesmosis sprains. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A prospectively collected National Hockey League (NHL) database was analyzed from the 2006-2007 to 2011-2012 seasons to assess return to play after an injury. A separate retrospective review of ankle MRI scans from professional hockey players with a documented high ankle sprain sustained between 2007 and 2012 was performed. Injuries were classified on MRI as complete or partial tears of the anterior-inferior tibiofibular ligament (AITFL), posterior-inferior tibiofibular ligament (PITFL), anterior talofibular ligament (ATFL), posterior talofibular ligament (PTFL), calcaneofibular ligament (CFL), and deltoid ligament. Fractures, bone contusions, and osteochondral lesions were also recorded. RESULTS: A total of 105 NHL athletes sustained high ankle sprains over the 5 seasons studied. Of these athletes, 85 were unable to play and missed a median of 8 games (range, 0-65 games). A retrospective MRI evaluation of 21 scans identified complete AITFL tears in 13 (62%) and high-grade partial tears in 5 (24%) cases. In contrast, the PITFL was partially torn in 9 (43%) and normal in 12 (57%) cases. Bone contusions were seen in 71% of cases and lacked a consistent pattern. The most commonly associated ligamentous injury was of the ATFL, which was injured in 52% of cases (11/21; 3 complete and 8 partial). There was no difference in the mean number of days lost when players were stratified by patterns of injury (incomplete/complete AITFL tear ± additional ligamentous injury, bone contusion, syndesmosis width). CONCLUSION: A high ankle sprain resulted in significant variations in time of recovery among professional hockey players. A torn AITFL and bone bruising were the most common patterns of injury. Although MRI can be used to confirm the diagnosis of a syndesmosis injury, it did not predict return to play in this population.